Reading of the Week: Euthanasia, Psychiatry, and the Thienpont et al. paper

The Belgian Euthanasia Law (2002) defines euthanasia as the physician’s “act of deliberately ending a patient’s life at the latter’s request,” by administering life-ending drugs.In Europe, psychological suffering stemming from either a somatic or mental disorder is acknowledged as a valid legal basis for euthanasia only in Belgium, the Netherlands and Luxembourg.In the Netherlands and Luxembourg, the term ‘assisted suicide’ is used when the life-ending drugs are taken orally, but in Belgium, the term ‘euthanasia’ is used whether the drugs are received orally or intravenously.

So begins a new paper on euthanasia in Belgium.

The topic is fascinating and it’s also highly relevant in Canada. As you will recall, Carter v. Canada – the Supreme Court ruling made earlier this year – speaks directly to the right to doctor-assisted suicide. (I’ll return to this point in a moment.)

This week’s Reading: “Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study” by Dr. Lieve Thienpont et al., which was just published online at BMJ Open.

Though much has been written about Belgium and euthanasia (a June Reading considered a New Yorker essay on the topic), little data has been analyzed. And that’s what makes the Thienpont et al. paper interesting. A quick summary: in a first-of-it-kind paper, the authors consider 100 psychiatric patients requesting euthanasia – from their diagnosis to their final outcome. It should be noted that the first author is a leading proponent of euthanasia and was actively involved in the care and decision making of these patients.

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Reading of the Week: Dr. Linda Gask’s New Book (Depression: Week 3 of 3)

This is a story about overcoming depression and also about coming to terms with loss. The two are closely related to each other. I know about this not just from my personal experience, but because I am a psychiatrist. I have specialised in treating those who suffer from the same problems which have afflicted me throughout my adult life. I’ve survived and come through it, and I know others can too.

So opens a new book by Dr. Linda Gask, a British psychiatrist. This Week’s Reading: an exclusive excerpt from The Other Side of Silence: A Psychiatrist’s Memoir of Depression, which was just published by Summersdale Publishers Ltd.


This Reading is the third part in a three-part series on depression.

Two weeks ago: a look at better psychopharmacological management.

Last week: consideration of better treatment in the primary care setting.

This Week: a look at the burden of illness on the patient and the psychiatrist.

(And this isn’t Mad Men Season 4. Miss a week and you aren’t lost.)

Dr. Gask has had a remarkable career. Beyond clinical work, she’s had a sparkling academic career, with a focus on mental-health policy and practice. She’s published papers and book chapters; she’s trained residents; she’s lectured all over the world. She was a Harkness Fellow at the Group Health Research Institute in Seattle, Washington. And she has also worked as a consultant for the World Health Organization and with the World Psychiatric Association.

GaskDr. Linda Gask

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Reading of the Week: Depression and Primary Care (Depression: Week 2 of 3)

Depression is a common psychiatric disorder and a major contributor to mortality and morbidity worldwide. Over the past decade in Sweden, work absence because of mental ill health has risen markedly and depression is a major factor. Substantial societal costs are associated with the disorder, which affects up to 15% of the population at any one time and tends to be recurrent. There are compelling reasons to investigate alternative treatments for depression. Although effective treatments exist, most people with the disorder never seek professional help. Among those that do, only half appear to benefit. Adherence with medication is often poor and waiting times for cognitive–behavioural therapy (CBT) can be lengthy, resulting in more entrenched symptoms and a worse long-term prognosis. As general medical practitioners are frequently the main care providers for depression, treatment options that are non-stigmatising, have few side-effects and can readily be prescribed in community healthcare settings are needed.

So begins a new paper that considers depression treatment in Sweden. These issues sound very familiar. Reading over this list of problems – the burden of illness, the inaccessibility of care, etc. – we could replace Sweden with Canada. And that’s why this paper is so relevant to us.

This week’s Reading: “Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: randomised controlled trial” by Mats Hallgren et al., which was just published in the British Journal of Psychiatry.

Mats Hallgren

A quick summary: this is a smart paper seeking ways to improve the treatment of depression in the primary care setting. How to achieve better results? Hallgren et al. consider exercise and Internet-based CBT, and compare such interventions to the usual care. Continue reading

Reading of the Week: Depression and Measurement-Based Care (Depression: Week 1 of 3)

Major depression is common, leading to marked suffering for patients and families and causing physical and mental disability, with a substantial economic burden. Although major depression is prevalent across different cultures and effective pharmacological and psychosocial interventions are available, low remission rates in clinical practice are discouraging. Poor outcomes are related to inadequate dose and duration of pharmacotherapy, poor treatment adherence, high dropout, and frequent as well as unnecessary medication changes. In addition, inconsistency of treatment strategies among clinicians is common. Even in current, guideline-driven practice, there are often wide variations in clinicians’ behaviors, resulting in practice bias rather than a tailored and individualized treatment algorithm.

So opens a new paper that has a large goal: trying to reduce that “wide variation” and improve patient care.

This week’s Reading: “Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters” by Tong Guo et al., just published online (and ahead of print) by The American Journal of Psychiatry.

Find the paper here:

Here’s a quick summary: big study, big journal, and big implications for depression management (and, yes, your patients). In a head-to-head comparison, patients did better when depression management included an algorithm for medications rather than regular psychiatrist care. Continue reading

Reading of the Week: Immigration and Psychosis (and Canada)

Meta-analytic reviews suggest that international migrants have a two to threefold increased risk of psychosis compared with the host population, and the level of risk varies by country of origin and host country. This increased risk may persist into the second and third generations. Incidence rates are not typically found to be elevated in the country of origin; therefore it is believed that the migratory or postmigration experience may play a role in the etiology.

The migration-related emergence of psychotics disorders is a potential concern in Canada, which receives 250,000 new immigrates and refugees each year. However, there is a notable lack of current epidemiological information on the incidence of psychosis among these groups.

So begins a new paper that seeks to answer a basic question: are there certain migrant groups more at risk of psychotic disorders in Canada?

This week’s Reading: “Incidence of psychotic disorders among first-generation immigrants and refugees in Ontario” by Kelly K. Anderson et al., which was published in the CMAJ in June.

Kelly K. Anderson

Of course, studying the incidence of psychotic disorders in immigrant populations isn’t exactly novel – there is a rich literature in this field. And the Canadian angle isn’t novel either – as the paper points out, previous studies have considered B.C. hospital admission rates for schizophrenia in European migrants in the early 1900s.

But this paper aims to consider recent data and Canadian data – relevant in a country that takes in 250,000 migrants a year. The paper focuses on Ontario, where first generation migrants constitute almost a third of the population.

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Reading of the Week: Is CBT Losing Its Effectiveness? The Johnsen and Friborg Paper

Depressive disorders (DDs) can be highly disabling and are ranked third in terms of disease burden as defined by the World Health Organization, and first among all psychiatric disorders in terms of disability adjusted life years. In addition, DDs seem to be rising globally, and a 20% annual increase in its incidence has been predicted. Improvements in treatment methods and prevention measures, and the availability of community psychiatric services are, therefore, as important as ever before.

So begins, without much controversy, this week’s Reading – which happens to be one of the most controversial papers of the year.

This meta-analysis has been mentioned in newspapers and blogs. No wonder – in 22 pages, it raises questions about the effectiveness of a major psychiatric treatment: cognitive behavioural therapy.

The Reading: “The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis” by Tom J. Johnsen and Oddgeir Friborg, recently published in the prestigious Psychological Bulletin.

The full paper can be found here:

Tom J. Johnsen

A quick summary: analyzing data from 70 studies over nearly four decades, Johnsen and Fribourg find CBT to have become less effective at reducing depressive symptoms. Continue reading

Reading of the Week: Housing First and At Home/Chez Soi

Homelessness is a significant social problem in Toronto, Canada’s largest and most ethnically diverse urban center, where approximately 29,000 individuals use shelters each year and roughly 5,000 people are homeless on any given night.

So opens this week’s Reading. The sentence is simple and direct; the facts conveyed are haunting. But this week’s Reading is ultimately a good news story. Actually, it’s a very good news story.

The Reading: “Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial” by Vicky Stergiopoulos et al., which has just been published in PLOS ONE.

Dr. Vicky Stergiopoulos

Here’s a quick summary: offer the homeless housing, and they not only gain housing stability but end up drinking less and are hospitalized less. Continue reading

Reading of the Week: Psychiatry’s Identity Crisis

American psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.

With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.

Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.

So begins this week’s Reading, which considers the state of psychiatry, and psychiatric research funding.

Here’s a quick summary: the author suggests that the neuroscience revolution is something of a bust and that psychotherapies are worthy of more study and use. This may seem like a strong argument. And it is – particularly given the bias of the author, who is, by his own description: “a psychiatrist and psychopharmacologist who loves neuroscience.”

This week’s Reading: “Psychiatry’s Identity Crisis” by Weill Cornell Medical College’s Richard A. Friedman was recently published by The New York Times.

The article can be found here:

Dr. Richard A. Friedman

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Reading of the Week: Insomnia and Its Treatment

Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent treatment package that usually includes stimulus control, sleep restriction, and cognitive therapy and has emerged as the most prominent nonpharmacologic treatment for chronic insomnia. Previous meta-analyses have found that CBT-I improves sleep parameters and sleep quality at post treatment and follow-up for adults and older adults. Most of these studies selected individuals with primary insomnia, excluding patients with co-morbid psychiatric and medical conditions. However, patients with insomnia who present to internists and primary care physicians are likely to report comorbid conditions associated with the sleep disturbance. Furthermore, insomnia was previously conceptualized as a symptom arising from the comorbid disorder and treatment was targeted at the underlying disorder. However, accumulating evidence indicates that insomnia can have a distinct and independent trajectory from the comorbid disorder, thus indicating a need for separate treatment from the comorbid condition.

So begins this week’s Reading, which considers CBT-I for people with insomnia. Here’s a quick summary: big study, big journal – and big relevance to your patients.

This week’s Reading: “Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis” by Jade Q. Wu et al. was just published in JAMA Internal Medicine. Find the paper here.


Wu et al. consider a very common problem: insomnia. Many patients – whether they have mental health issues or physical health issues – struggle with insomnia. Boston University health economist Austin Frakt has written about his insomnia for The New York Times. He notes that he decided to receive treatment when:

One weekend afternoon a couple of years ago, while turning a page of the book I was reading to my daughters, I fell asleep. Continue reading

Reading of the Week: ADHD and Overdiagnosis

Overdiagnosis in psychiatry occurs where patients are identified with a mental disorder when they do not have significant impairment and would not be expected to benefit from treatment. These problems can arise even when diagnostic criteria are met, that is, in the presence of milder symptoms that fall close to, or within, a normal range on a diagnostic spectrum. Overdiagnosis can lead to unnecessary labelling, unneeded tests, unnecessary therapies, and inflated health care costs. In medicine, with the best of intentions, practice has come to favour more tests and more treatments, all of which tend to drive overdiagnosis. This problem may be worsened by a prevailing cultural ethos that more is better.

Outside of psychiatry, there are clear examples of overdiagnosis. For example, screening programs designed to detect early stages of certain cancers appear to increase incidence estimates, but may have no discernable effect on mortality…

Psychiatry has followed this trend. It has been estimated that at least 40% to 50% of the population will meet criteria for at least 1 psychiatric diagnosis during their lifetime. The current system of nosology in psychiatry, based on phenomenology, that is, subjective reports and clinical observations, encourages overdiagnosis. The presence or absence of mental disorders is not defined by biomarkers, allowing diagnostic constructs to describe broad spectra that cross over into normality.

So begins a short, sharp article on overdiagnosis in psychiatry that has just been published. The authors raise significant issues about psychiatry in general and adult ADHD in particular – they argue that the DSM diagnosis is flawed and impractical; they take aim at patients (yes, patients); they then turn their sites on researchers and industry.

The comments of sensational journalists? The skewed opinion of Scientologists on a blog? Actually, the Reading comes from the pages of The Canadian Journal of Psychiatry and, for the record, the paper’s first author is one of the most prominent psychiatrists in the country; Dr. Joel Paris is the past chair of McGill’s Department of Psychiatry and the author of more than a dozen books.

This week’s Reading: “Is Adult Attention-Deficit Hyperactivity Disorder Being Overdiagnosed?” by Paris et al.

Here’s the link:

The Canadian Journal of Psychiatry has always been worth reading, but its new editor, Dr. Scott Patten, has taken this journal to the next level. And, in my opinion, this “perspective” paper is a must-read – one of the most important papers written this year. Continue reading